Awareness typologies, long-term emotional adjustment and psychosocial outcomes following acquired brain injury

Unawareness of deficits in ischemic injury: role of the cingulate cortex

Reduced awareness of illness is a well-known phenomenon that has been studied in patients with vascular disease, but the precise nature of their executive dysfunction is an intriguing question that still has to be resolved. It would be particularly interesting to study patients with reduced awareness of disease possibly related to vascular lesions of the prefrontal cortex. Due to the clinical importance of the case, here we present a patient with a selective right anterior cingulate ischemic injury and impaired awareness of deficits. We suggest that the cingulo-frontal area dysfunction may represent one of the corresponding neurobiological substrates of his persistent unawareness, which has not yet been evaluated in the literature on patients with acquired brain injury (ABI).

Alexithymia and avoidance coping following traumatic brain injury

BACKGROUND

Individuals who develop maladaptive coping styles after traumatic brain injury (TBI) usually experience difficulty expressing their emotional state, increasing the risk of psychological distress. Difficulties expressing emotion and identifying feelings are features of alexithymia, which is prevalent following TBI.

OBJECTIVE

To examine the relations among coping styles, alexithymia, and psychological distress following TBI.

PARTICIPANTS

Seventy-one patients with TBI drawn from a head injury clinic population and 54 demographically matched healthy controls.

MAIN MEASURES

Toronto Alexithymia Scale-20, Estonian COPE-D Inventory, Beck Depression Inventory-II, and Beck Anxiety Inventory.

RESULTS

The participants with TBI exhibited significantly higher rates of alexithymia and psychological distress and lower levels of task-oriented coping than healthy controls. Levels of avoidance coping and psychological distress were significantly higher in a subgroup of TBI patients with alexithymia than in a non-alexithymic TBI subsample. There were significant relations among alexithymia, avoidance coping, and levels of psychological distress. Regression analysis revealed that difficulty identifying feelings was a significant predictor for psychological distress.

CONCLUSION

Early screening for alexithymia following TBI might identify those most at risk of developing maladaptive coping mechanisms. This could assist in developing early rehabilitation interventions to reduce vulnerability to later psychological distress.

Cognitive Assessment and Rehabilitation Pathway for Stroke (CARPS)

Complex cognitive impairments are common after stroke and they can significantly impede individuals' progress in rehabilitation. Treatment strategies that allow patients to compensate for such deficits are therefore an important part of multidisciplinary rehabilitation, as acknowledged by various clinical guidelines. In part due to the heterogeneity of poststroke cognitive impairments, the evidence base for treatments in this area is often unclear or inconsistent. There are no straightforward clinical tools or guidelines available to facilitate poststroke cognitive rehabilitation across cognitive domains. The present article proposes a cognitive assessment and rehabilitation pathway for stroke (CARPS), which aims to provide a structure to guide stroke rehabilitation teams in this difficult area of clinical practice. Practical treatment strategies are also discussed in some detail. Finally, the limitations of the proposed pathway are acknowledged, as is the importance of further research.

Development and Preliminary Psychometric Evaluation of the Self-Perceptions in Rehabilitation Questionnaire (SPIRQ) for Brain Injury Rehabilitation

OBJECTIVE. The Self-Perceptions in Rehabilitation Questionnaire (SPIRQ) is a brief measure developed to monitor client self-perceptions, motivation, and emotional reactions throughout rehabilitation. We describe the SPIRQ’s development and preliminary psychometric evaluation.

METHOD. One hundred five adults with traumatic brain injury attending two brain injury rehabilitation units completed the SPIRQ during occupational therapy sessions. A subset (n = 33) completed the SPIRQ twice over a 5- to 7-day interval to examine test–retest reliability.

RESULTS. Exploratory factor analysis yielded three factors: Changes in Self and Life Plans, Self in Rehabilitation, and Emotional Reactions. Their internal consistency was sound (αs = .72–.83). Test–retest reliability was generally acceptable (rs = .67–.81), and scores did not significantly change between testing occasions (p > .05).

CONCLUSION. We found preliminary support for the SPIRQ scales’ reliability and construct validity. Future empirical evaluation and potential clinical applications of the SPIRQ in occupational therapy are discussed.

Acceptance and Commitment Therapy (ACT) for Psychological Adjustment after Traumatic Brain Injury: Reporting the Protocol for a Randomised Controlled Trial

Following a severe traumatic brain injury (TBI) there is a complex presentation of psychological symptoms which may impact on recovery. Validated treatments addressing these symptoms for this group of people are limited. This article reports on the protocol for a single-centre, two-armed, Phase II Randomised Control Trial (RCT) to address the adjustment process following a severe TBI. Participants will be recruited from Liverpool Brain Injury Rehabilitation Unit and randomly allocated to one of two groups, Acceptance and Commitment Therapy (ACT) or an active control (Befriending). The active treatment group utilises the six core processes of ACT with the intention of increasing participation and psychological flexibility and reducing psychological distress. A number of primary and secondary outcome measures, administered at assessment, post-treatment and 1-month follow-up, will be used to assess clinical outcomes. The publication of the protocol before the trial results are available addresses fidelity criterion (intervention design) for RCTs. This ensures transparency in the RCT and that it meets the guidelines according to the CONSORT statement. The protocol has also been registered on the Australian New Zealand Clinical Trials Registry ACTRN12610000851066.

Moving Ahead: A New Centre of Research Excellence in Brain Recovery, Focusing on Psychosocial Reintegration Following Traumatic Brain Injury

Severe traumatic brain injury (TBI) is the most common cause of brain injury in the Western world and leads to physical, cognitive and emotional deficits that reduce independence. Changes to psychosocial function are the most disruptive, resulting in vocational difficulties, family stress and deteriorating relationships, and are a major target for remediation. But rehabilitation is expensive and its evidence base is limited. Thus, new collaborative initiatives are needed. This article details the development of ‘Moving Ahead’, a model for a Centre of Research Excellence (CRE) for Traumatic Brain Injury Rehabilitation. This CRE offers several major innovations. First, it provides an integrated, multi-faceted approach to addressing psychosocial difficulties embracing different clinical standpoints (e.g., psychological, speech pathology, occupational therapy) and levels of investigation (e.g., basic science to community function) across the lifespan. It is based upon a close relationship with clinicians to ensure transfer of research to practice and, conversely, to ensure that research is clinically meaningful. It provides an integrated platform with which to support and train new researchers in the field via scholarships, postdoctoral fellowships, websites, meetings, mentoring and across-site training, and thus build workforce capacity for individuals with TBI and their families. It has input from the international community to contextualise research more broadly and ensure scientific rigour. Finally, it provides collaboration across sites to facilitate research and data collection.

Agreement between parent-adolescent ratings on psychosocial outcome and quality-of-life following childhood traumatic brain injury

OBJECTIVE

This study investigated parent-adolescent agreement in long-term psychosocial and quality-of-life (QoL) outcomes. The sample comprised adolescents aged 15-18 years, who sustained childhood traumatic brain injury (TBI) between birth and 5 years of age.

METHODS

Thirty-three participants (17 adolescents with TBI and 16 TBI parent-proxies) were involved in the study which compared parent and adolescent ratings on the Sydney Psychosocial Reintegration Scale-Child form (SPRS-C) and the Pediatric Quality-of-Life Inventory (PedsQL). The questionnaires were administered through phone interviews.

RESULTS

As hypothesized, parent-adolescent agreement was acceptable for psychosocial outcome (intra-class coefficient [ICC] of 0.844, p < 0.001), whereas discrepancies were found for ratings of QoL (ICC of 0.506, p = 0.092).

CONCLUSION

The finding that parents and adolescents agree on psychosocial outcome is promising for those instances when the patient is unable to report; however, discrepancies regarding QoL suggest caution needs to be taken when interpreting parent-rated QoL data.

Association of depressive symptoms with functional outcome after traumatic brain injury

OBJECTIVE

To test whether improved functional status correlates with more depressive symptoms after traumatic brain injury (TBI). This is based on the concept that increasing awareness of deficits may exacerbate depression, even while survivors are making functional improvements.

PARTICIPANTS

A total of 471 individuals with TBI (72% white; 71% men; median Glasgow Coma Scale (GCS) score = 11) enrolled during acute care or inpatient rehabilitation and followed up at a median of 6 months.

MAIN MEASURE

Beck Depression Inventory-II (BDI-II), Glasgow Outcome Scale-Extended, and Functional Status Examination (FSE).

RESULTS

We found significant Spearman rank order correlations between BDI-II scores and the total FSE as well as all domains of the FSE. Lower functional levels correlated with more depressive symptoms. Modeling of predictive factors, including subject characteristics, injury-related characteristics, and outcome measures, resulted in 2 models, both containing age and GCS along with other factors.

CONCLUSION

The relation between depressive symptoms and functional outcomes is complex and a fertile area for further research. The authors would encourage clinicians to monitor patients for depressive symptoms to help to prevent the detrimental impact on recovery.

The adaptation process following acute onset disability: an interactive two-dimensional approach applied to acquired brain injury

Objective:

To describe a new model of the adaptation process following acquired brain injury, based on the patient’s goals, the patient’s abilities and the emotional response to the changes and the possible discrepancy between goals and achievements.

Background:

The process of adaptation after acquired brain injury is characterized by a continuous interaction of two processes: achieving maximal restoration of function and adjusting to the alterations and losses that occur in the various domains of functioning. Consequently, adaptation requires a balanced mix of restoration-oriented coping and loss-oriented coping. The commonly used framework to explain adaptation and coping, ‘The Theory of Stress and Coping’ of Lazarus and Folkman, does not capture this interactive duality.

Relevant theories:

This model additionally considers theories concerned with self-regulation of behaviour, self-awareness and self-efficacy, and with the setting and achievement of goals.

The two-dimensional model:

Our model proposes the simultaneous and continuous interaction of two pathways; goal pursuit (short term and long term) or revision as a result of success and failure in reducing distance between current state and expected future state and an affective response that is generated by the experienced goal-performance discrepancies. This affective response, in turn, influences the goals set. This two-dimensional representation covers the processes mentioned above: restoration of function and consideration of long-term limitations. We propose that adaptation centres on readjustment of long-term goals to new achievable but desired and important goals, and that this adjustment underlies re-establishing emotional stability. We discuss how the proposed model is related to actual rehabilitation practice.

The Effect of Choice on Compliance Using Telerehabilitation for Direct Attention Training: A Comparison of “Push” Versus “Pull” Scheduling

Home practice, a type of asynchronous telerehabilitation, is an integral component of most rehabilitation regimens. Exercise drills conducive to home practice have been shown to be beneficial in remediating acquired impairments in attention, speech, language, and voice. A variety of interacting psychological, cognitive, and socioenvironmental factors contribute to short- and long-term exercise adherence. There has been little research evaluating the personal characteristics most likely to motivate clients to engage in their rehabilitation and follow through with prescribed activities. In this project, we were interested in using telerehabilitation to learn more about factors that might increase clients' adherence to home exercise; we used direct attention training as our experimental domain. The study used a single-subject, alternating treatment experimental design with 2 participants to compare compliance on home attention exercises under two conditions. The Attention Process Training-3 (APT-3, 2010) direct attention training program, delivered via the Televised Assistance Program (TAP) system, allowed us to compare compliance under (a) conditions when the client had no control over the start-up of the program (push) versus (b) conditions when the client had to initiate turning on the program to do the home program (pull). Results showed that home exercise adherence was higher for both participants under the nonautonomous push condition. This ran counter to our hypothesis, based on the therapy literature, that suggested patients are more likely to follow through with home assignments when practice is under their control. We discuss our findings with respect to the interaction between self-efficacy, therapy beliefs, and autonomy for patients with acquired brain injury.

Metacognitive unawareness correlates with executive function impairment after severe traumatic brain injury

The aim of this study was to evaluate clinical, neuropsychological, and functional differences between severe traumatic brain injury (TBI) outpatients with good and/or heightened metacognitive self-awareness (SA) and those with impaired metacognitive SA, assessed by the Patient Competency Rating Scale (PCRS). Fifty-two outpatients were recruited from a neurorehabilitation hospital based on the following inclusion criteria: 1) age > or = 15 years; 2) diagnosis of severe TBI; 3) availability of neuroimaging data; 4) post-traumatic amnesia resolution; 5) provision of informed consent.

MEASURES

A neuropsychological battery was used to evaluate attention, memory and executive functions. SA was assessed by the PCRS, which was administered to patients and close family members. Patients were divided into two groups representing those with and without SA. Patients with poor SA had more problems than those with good SA in some components of the executive system, as indicated by the high percentage of perseverative errors and responses they made on the Wisconsin Card Sorting Test. Moreover, a decrease in metacognitive SA correlated significantly with time to follow commands (TFC). This study suggests the importance of integrating an overall assessment of cognitive functions with a specific evaluation of SA to treat self-awareness and executive functions together during the rehabilitation process.

Sensitivity and specificity of the Beck Depression Inventory-II in persons with traumatic brain injury

OBJECTIVES

Our objective was to examine the Beck Depression Inventory-II (BDI-II) in a traumatic brain injury (TBI) sample using a receiver operating characteristic (ROC) curve to determine how well the BDI-II identifies depression. An ROC curve allows for analysis of the sensitivity and specificity of a diagnostic test using various cutoff points to determine the number of true positives, true negatives, false positives, and false negatives.

DESIGN

This was a secondary analysis of data gathered from an observational study. We examined BDI-II scores in a sample of 52 veterans with remote histories of TBI.

SETTING

This study was completed at a Veterans Affairs (VA) Medical Center.

PARTICIPANTS

Participants were veterans eligible to receive VA health care services.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Outcome measures included the BDI-II and the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-IV).

RESULTS

We generated an ROC curve to determine how well the BDI-II identifies depression using the SCID-IV as the criterion standard for diagnosing depression, defined here as a diagnosis of major depressive disorder. Results indicated a cutoff score of at least 19 if one has a mild TBI or at least 35 if one has a moderate or severe TBI. These scores maximize sensitivity (87%) and specificity (79%).

CONCLUSIONS

Clinicians working with persons with TBI can use the BDI-II to determine whether depressive symptoms warrant further assessment.

Executive function and metacognitive self-awareness after severe traumatic brain injury

The objective of this study is to identify the clinical, neuropsychological, neuropsychiatric, and functional variables that correlate with metacognitive self-awareness (SA) in severe traumatic brain injury (TBI) outpatients and to assess the influence of the same variables on the sensory-motor, cognitive, and behavioral-affective indicators of SA. This cross-sectional observational study evaluated 37 outpatients from May 2006 to June 2007 in a neurorehabilitation hospital on the basis of the following inclusion criteria: (1) age 8); (3) posttraumatic amnesia (PTA) resolution; (4) capacity to undergo formal psychometric evaluation despite cognitive and sensory-motor deficits; (5) absence of aphasia; (6) availability of informed consent. A neuropsychological battery was used to evaluate attention, memory, and executive functions. SA was assessed by the awareness questionnaire (AQ), administered to both patients and relatives. Decreased metacognitive self-awareness is significantly correlated with increased problems in some components of executive system, even when the AQ subscales were considered separately. The significant correlation found between some components of executive system and metacognitive self-awareness confirmed the importance of addressing this issue to treat SA contextually in the rehabilitation of executive functions.